Reports & Studies

This is an archival or historical document and may not reflect current policies or procedures.

Committee on Economic Security (CES)

"Social Security In America"

Part V

THE EXTENSION OF PUBLIC-HEALTH
SERVICES

The basic data for part V have
been abstracted from (1) Staff reports on "Risks to Economic Security
Arising out of Ill Health" (the sections on public-health services
derived from this source were prepared by W. F. Walker and Ira Y. Hiscock
under the direction of Edgar Sydenstricker) ; (2) A statement of Josephine
Roche, Assistant Secretary of the Treasury, made on February 4, 1935,
at the public hearing held by the Committee on Finance of the United States
Senate; and (3) Regulations Governing Allotments and Payments to States
From Fund Appropriated Under the Provisions of Section 601, Social Security
Act, for the Fiscal Year 1936, Issued by the Surgeon General

Chapter XVIII

THE EXTENSION OF PUBLIC-HEALTH
SERVICES

NO NATIONAL PROGRAM of economic security can be regarded in any
sense as complete or effective without adequate provision for meeting
the risks to security which arise out of ill health. Fear of sickness
with its attendant loss of earnings when the wage earner is disabled and
dread of the costs of medical care are specters which haunt the great
majority of the American people. Economic insecurity from illness is not
the consequence of a depression; it threatens people of small means even
in good times. The problem is not created in a depression period; it is
only exaggerated and made more severe.

Every careful study of the economic experience of wage-earning families
has revealed the inadequacy of individual savings to afford full protection
against the costs of ill health. Tens of millions of families live in
dread of sickness. Millions of families that are independent and self-sustaining
in respect to the ordinary, routine needs of life sacrifice other essentials
of decent living in order to pay for medical service. Three possibilities
are open to low-income families which suffer extensive illnesses: (1)
they may go without needed medical care; (2) they may carry the burden
of medical debts; or (3) they may rely upon the charity of doctors and
hospitals, or receive their services from tax-supported and philanthropic
agencies.

The annual money loss caused by sickness in families with incomes of
less than $2,500 a year in the United States in 1929 was estimated as
nearly $2,500,000,000. Of this huge sum about $1,500,000,000 represents
the expenses of these families for medical care and about $900,000,000
constitutes their loss in wages resulting from sickness. The cost of care
in sickness thus exceeds wage loss due to temporary disability. These
figures are direct costs. They ignore the much larger costs of sickness
represented by the losses in capital values of human life and the losses
to commerce and industry.

These enormous losses are not distributed equally among the people. Some
individuals have much more sickness than others in any given year. Actuarial
experience shows that among an average million persons there will occur
annually between 800,000 and 900,000

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cases of illness. This might seem to mean nearly one case of sickness
to each person. Actually, however, the economic burden will fall more
heavily on some than on others. For although 470,000 among an average
million persons will not be sick during a normal year, 460,000 will be
sick once or twice, and 70,000 will suffer three or more illnesses. Of
those who become ill, about one-fourth will be disabled for periods varying
from 1 week to the entire year. The situation may be visualized from the
actual experience in normal times of 1,000 typical families in large cities,
with annual incomes ranging from $1,200 to $2,000, as follows: 218 had
medical bills in a single year in excess of $100, and 80 in excess of
$200; of these 80 families 16 had medical costs ranging from $400 to $700,
or about one-third of the year's income, and 4 families had sickness bills
amounting to more than one-half of their incomes. All these costs were
additional to wage losses. The situation in families with less than $1,200
annual income is far worse, even in normal times.

The fact must be faced that, even if a minimum annual income of $2,000
could be maintained through various ways for American families, this amount
would still be insufficient to enable them individually to budget against
the costs of sickness. A substantial proportion of families in cities,
towns, and rural areas actually obtain no medical care, or receive insufficient
care during sickness. It has been shown by surveys that the proportion
of families receiving inadequate care is largest among those with small
incomes and that, step by step, as family income increases the proportion
of families with inadequate care diminishes. In normal times, about one-third
to one-half of all the families who have to seek public or private charity
are compelled to do so because of the economic effects of accident and
illness.

Thus, the risks to economic security arising out of ill health are of
three kinds, namely:

(1) Loss of efficiency and health itself, and thereby loss of the capacity
to be employed;

(3) Costs of medical care to gainfully employed persons and their families.

PREVENTION OF ILLNESS

As stated by the medical advisory board of the Committee on Economic Security:
A logical step in dealing with the risks and losses of sickness is to
begin in preventing sickness so far as is possible.

Much progress has been made in this respect, yet the fact remains that
despite great advances in medicine and public-health protection,

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millions of our people are suffering from diseases and thousands die
annually from causes that are preventable. The mortality of adults of
middle and older ages has not been appreciably diminished. With the changing
age composition of our population the task of health conservation must
be broadened to include adults as well as children.

Evidence is accumulating that the health of a large proportion of the
population is being affected unfavorably by the depression. The rate of
disabling sickness was found to be 48 percent higher among families having
no employed wage earners in 1932 than in families having full-time workers.
The group of workers that had dropped from fairly comfortable circumstances
to relief rolls during the depression showed a rate of disabling illness
73 percent higher than that of their more fortunate neighbors who had
remained in the comfortable class.{1} For the first time in many decades
the annual death rate in our large cities has increased, the rate for
1934 being higher than for 1933 despite the absence of any serious epidemics.{2}
Concurrently with these evidences of increased need, local appropriations
for public health have been decreased on the average 20 percent since
1930. The per-capita expenditure from tax funds for public health in 53
cities in 1934 was 77.5 cents as contrasted with 93.8 cents in 1931.{3}

It has long been recognized that the Federal, State, and local governments
all have responsibilities for the protection of all the population against
disease. The Federal Government has recognized its responsibility in this
respect in the public-health activities of several of its departments.
There also are well-established precedents for Federal aid for State and
local health administration and for the loan of technical personnel to
States and localities.

A comprehensive, Nation-wide program of lessening the risks to economic
security must include adequate provision of effective measures for the
prevention of ill health through organized public-health work. The soundness
of the principle of prevention is obvious. Its application here, however,
should be viewed in the light of four other broad considerations, as follows:

(1) Although one-third of the burden of preventable illness and premature
death has been lifted in progressive communities since modern public-health
procedures were introduced, there is recognized opportunity for continued
progress in this field. Only a fraction of the population has benefited
to the fullest extent from the application of existing knowledge of disease
prevention through public-health procedures.

(2) The policy of leaving to localities and States the entire responsibility
for providing even minimal public-health facilities and services has failed
in large measure. Only 21 percent (75{4} counties and 102 cities{5}) of
the counties and cities of the United States have thus far developed a
personnel and service which can be rated as even a satisfactory minimum
for the populations and the existing problems. The Federal Government
has a definite responsibility for the protection of all the Nation's population
against disease.

(3) The responsibility of the Federal Government for national health
is well established in the United States Public Health Service and in
several other Federal agencies, such as the Children's Bureau, the Bureau
of the Census, the Office of Education, the Food and Drug Administration,
and the Bureau of Animal Industry. The precedent of Federal aid to States
for State health administration and local public-health facilities also
has been established in various laws for grants-in-aid and in loans of
technical personnel to States and localities.

(4) Public health has been demonstrated as a sound economic investment.
Public-health authorities estimate that our annual national economic loss
in wage earnings and in other items incident to preventable sickness directly
attributable to lack of reasonably efficient rural health service is over
$1,000,000,000. On the other hand, where reasonably effective health programs
have been developed, it has been demonstrated that expenditures for carefully
planned health programs executed by trained workers yield large dividends.
To fail to include the fullest possible use of this powerful preventive
weapon in a program of economic security would be short-sighted-even stupid.

Little need be said with respect to the need for outside assistance to
certain counties too poor to meet the entire cost of public-health service.
In many of our States there are counties in which the taxable wealth or
other source of revenue is so small that adequate local appropriations
cannot be made for a health department without making the allotment for
health out of all reasonable proportion to expenditures for other necessary
functions of government. State health departments must give assistance
to the counties in this group if the people in these communities are to
enjoy the benefits of health protection to which they are--certainly from
a humane standpoint--entitled as citizens of this country.

With regard to the need for outside aid for demonstration purposes, it
is well known to all national and State agencies which have endeavored
to promote the expansion of full-time health service in the past that
it is almost impossible to induce local boards of county commissioners
to make the initial appropriation for the establishment of a new full-time
county health unit unless financial aid can be offered from an outside
source. The reason is not hard to under-

{5} Public Health Reports, vol. 49, no. 5, Feb. 2, 1934 ; Committee
on Administrative Practice of the American Public Health Service in cooperation
with United States Public Health Service, "Municipal Health Department
Practice for the Year 1923, Based Upon Surveys of the 100 Largest Cities
in the United States", Public Health Bulletin. No. 164; Research
Division of the American Child Health Association, AHealth
Survey of 86 Cities (American Child Health Association,
New York, 1925).

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stand; health work, to a large extent, does not deal with material things.
It has for its objective the prevention of catastrophe which may occur
in the future. The wisdom of expending public funds for school buildings
and roads and for maintenance of our schools is apparent to anyone, because,
we see and use the buildings and roads and know that our children use
the schools. Except to statisticians, who are trained to use death rates
and other "measuring rods" for demonstrating the effectiveness
of health work, the anticipated results of such work are often not tangible.
It is difficult, therefore, to persuade local appropriating bodies to
provide funds to support an activity the result of which cannot be readily
demonstrated in advance of the expenditure.

The situation in many of our smaller cities, and in some of the larger
ones, is almost as bad as that existing in a large part of our rural area.
There are numerous urban communities throughout the country in which such
health activities as are being carried on today are under the direction
of part-time physicians engaged in private practice or lay health officers
untrained in modern public-health administrative practice. In some of
these communities such health protection as has been afforded has been
largely incidental to improvements instituted for economic and esthetic
reasons or to ready access of the population to good medical care rather
than a credit to activity of the health department. In many of our cities
the chief health department activity still consists largely in the inspection
of private premises for nuisances having little bearing on public health
and an attempt to control communicable diseases through quarantine procedure--admitted
by leading health workers, in this day of scientific control methods,
to be of little avail in reducing the incidence of such diseases. More
specifically it may be pointed out that many of the milk supplies for
urban communities are still far from satisfactory, and that the unsightly,
open-back, unsanitary privy still exists in the outlying sections of most
of our small cities, with the result that typhoid fever is rapidly becoming
more prevalent in towns and small cities than in the rural areas.

Nor is the need for extension of public-health service confined to rural
and urban health organizations. Not more than half of the State health
departments are adequately staffed or satisfactorily equipped to render
the service which they alone can give regardless of the extent to which
local facilities may be developed. Specific reference is made to divisions
of vital statistics, laboratories, and sanitary engineering service for
the supervision of local water supplies, sewage disposal, and other environmental
sanitation activities. At least a third of the States are not now able
to promote the establishment of full-time local health departments or
to give proper super-

320

vision to local health work because of the lack of properly trained scientific
personnel, capable of performing such duty, on the State health department
staff.

Before any real progress can be made in the extension of full-time local
health service, there must be created in each State a reserve of trained
health officers, public-health nurses, sanitary engineers, and inspectors
to fill the positions which will be established in the new units, for
in spite of the curtailment of appropriations for health work in recent
years there is a shortage of individuals trained for health work. Until
the public-health service throughout the country can offer careers which
will attract qualified workers and warrant specialized training in colleges,
medical schools, and universities, it will be necessary to raise personnel
standards gradually. Opportunities for graduate study, extension courses,
and demonstrations under experienced officials offered to or required
of personnel in office may serve to bring personnel standards to a level
of good public-health practice.

PREVENTABLE DISEASES AND
MORTALITY

While it is true that the general death rate and the rates for tuberculosis
and infant mortality for the country as a whole declined to the lowest
figures on record in 1933, we should not be misled by this fact into the
belief that further safeguards of the Nation's health are unnecessary.
These death rates do not tell the whole truth, Edgar Sydenstricker recently
said: "The plain fact must be faced that notwithstanding great advances
in medicine and public-health protection, the American people are not
so healthy as they have a right to be. Millions of them are suffering
from diseases and thousands annually die from causes that are preventable
through the use of existing scientific knowledge and the application of
common social sense." {7}

Ample evidence exists to support this sweeping statement. Approximately
120,000 infants under 1 year of age died in 1933. Although our infant
death rate has been reduced by half during the past 25 years, many of
the leading sanitarians in this country believe that mortality in the
infant age group can again be reduced by 50 percent. It is also confidently
believed by some of the leading authorities on tuberculosis that the 74,000
deaths which occurred from this disease in 1933 could again be cut in
half; and there is good reason to assume that, with proper health protection
for pros-

{6} Much of the factual data used in this chapter has appeared already
in the statement submitted by Assistant Secretary of the Treasury Josephine
Roche, to the Senate Committee on Finance, on Feb. 4, 1935. Economic Security
Act: Hearings before the Committee on Finance, United States Senate, 74th
Cong., 1st sess., on S. 1130 (U. S. Government Printing Office, Washington,
D. C., 1935), pp. 374-407.

{7} Sydenetricker, Edgar, "Health in the New Deal," Annals
of the American Academy of Political anal Social Science, vol. 176,
November 1934, p. 131.

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pective mothers, at least two-thirds of the 13,000 mothers who die each
year in childbirth could be saved.

Examination of the following table, compiled by the United States Public
Health Service from mortality figures of the United States Bureau of the
Census, shows that, in spite of the low general death rate, a total of
246,272 deaths occurred in the United States from causes that may be classed
as preventable.

Typhoid fever and diphtheria, both now regarded as diseases easily prevented
when known control measures can be applied, each took toll of more than
4,000 lives. Measles and whooping cough, often regarded by the uninformed
as simple and relatively harmless diseases of childhood, killed respectively
2,800 and 4,400 in 1933.

So far as the public was concerned, these appalling, unnecessary losses
of life went unnoticed, because of the lack of spectacular cir-

322

cumstances attending their occurrence; yet, had similar losses occurred
in a series of single disasters, such as an earthquake or the sinking
of an ocean liner, the Nation would have been shocked and our newspapers
would have carried front-page headlines for days.

Nor do deaths alone tell the whole story. It is estimated that for each
death from typhoid fever there are 10 cases; for each death from diphtheria,
12 cases. Although accurate figures are not available with respect to
cases of preventable diseases for the country as a whole (for the reason
that reporting of cases is not complete where satisfactory health organizations
do not exist), it is believed that a conservative estimate will place
the number of cases of typhoid fever at 43,000, and of diphtheria at 58,800,
in the United States in 1933.

A recent survey by the Public Health Service showed by actual blood test
of only 200,000 people in 11 southern States a total of 14,000 known cases
of malaria. This survey was made during the winter, when malaria is least
active, and included only school children. It is estimated that in the
whole population in the malarious section of the South there are, every
year, at the height of the malaria season, probably 6,750,000 cases of
malaria. Malaria is still one of the most serious problems of our southern
States and further knowledge of control methods is imperative. Here again,
the disease is not only of public-health importance but also of economic
importance, for each year malaria puts the wage earner out of the position
as the supporter of his family and makes both him and his family dependent
upon charity for their maintenance.

Three-quarters of a million patients with syphilis seek treatment annually
in the United States. Unfortunately, however, largely because they are
ignorant of the nature of the disease, because the cost of treatment is
high, or because facilities are lacking for the treatment at a cost that
can be borne by the patient, more than half of these cases do not obtain
treatment during. the first 2 years of their infection. This 2-year period
is the interval of greatest communicability and is of vast importance
in the control of syphilis. Adequate treatment during this time will not
only prevent the spread of this disease but will also make possible the
cure of the individual. For this reason it is of the utmost importance
that adequate treatment facilities for syphilis be made available for
all indigent and borderline economic cases in both rural and urban districts
of the United States.

The same factors exist in connection with the control of gonorrhea as
with syphilis. About 679,000 new cases of gonorrhea annually seek treatment
in this country. This number does not give a true picture of the actual
number of gonorrheal infections annually because many more patients with
gonorrhea than with syphilis

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fail to seek treatment. While the late and crippling manifestations of
the gonorrheal process are not as marked as in the case of syphilis, the
vast prevalence of gonorrhea makes the disease one of primary importance.

PAST AND PRESENT DEVELOPMENTS
OF THE FEDERAL PUBLIC HEALTH SERVICE

The activities of the Public Health Service were established by successive
laws enacted by Congress during the period 1799 to 1879. At the beginning
of the year 1880 the Service was concerned with the conduct of maritime
quarantine, control measures in the case of epidemics, establishment of
quarantine regulations for the prevention of the introduction of cholera,
collection of sanitary data and publication of the Public Health Reports,
and cooperation with State and local authorities in the prevention of
the introduction of infectious and contagious diseases.

Because independent studies of yellow fever and other diseases were made
necessary on account of their occurrence in epidemic form and because
it became apparent that provision should be made for conducting studies
relating to public health, the Hygienic Laboratory was established in
1887 for investigations of contagious and infectious diseases and matters
pertaining to public health. With the establishment of this laboratory
the work of the Service in the field of scientific research had its definite
origin. Scientific studies and investigations of yellow fever, cholera,
malaria, tuberculosis, pneumonia, and the potency of various gaseous disinfectants
were immediately undertaken. In 1901 a Hygienic Laboratory building was
provided by act of Congress, and the main work was divided into the four
large divisions: (1) Chemical, (2) biological, (3) pharmaceutical, and
(4) pathological.

In 1901 the organization of a Bureau division of scientific research
was effected. In 1902 another act of Congress required that establishments
manufacturing biologic products be inspected by a medical officer of the
Service and upon his report, when acted upon by the sanitary board of
the Service, is based the decision whether establishments shall be granted
licenses for the manufacture of these products.

The Scientific Research Division activities resulted in a gradual but
steady increase in work. Among the projects undertaken up to 1912 were
investigations into Rocky Mountain spotted fever, special studies of milk
in relation to public health, studies of Mexican typhus fever, and sanitary
surveys of pollution of navigable waters.

Long-time recognition of the need of additional authority to undertake
systematic field investigations of scientific and practical public-

324

health problems resulted in the act of Congress approved August 14, 1912,
when the name Public Health Service was given to the existing services
and the powers were broadened as follows:

The Public Health Service may study and investigate the diseases of
man and conditions influencing the propagation and spread thereof, including
sanitation and sewage and the pollution either directly or indirectly
of the navigable streams and lakes of the United States, and it may from
time to time issue information in the form of publications for the use
of the public.

The enactment of this law marked the beginning of a new epoch in the
development of public-health work by the Federal Government. For convenience
the organization of the Division of Scientific Research may be divided
into two general fields, laboratory stations and field offices, although
the activities of the two are so interrelated that no arbitrary boundary
can be set.

The laboratory stations carry on research into such problems as stream
pollution, Rocky Mountain spotted fever, cancer, public-health relations,
coordination of research by public-health officials and other scientists,
demonstrations of sanitary methods and appliances, breeding and rearing
of pure strains of animals in connection with the control of biologics.

Field investigation offices of the Service are developed and maintained
in accordance with the necessity arising in their particular fields of
work. These offices are not permanent, but their work may be enlarged
or terminated or additional offices established as the demand of research
work of the Public Health Service indicates. At present some of the activities
are investigations of heart disease, leprosy, malaria, nutritional diseases,
plague, child hygiene, milk, public-health methods, industrial hygiene
and sanitation, amebic dysentery, encephalitis, and poliomyelitis (infantile
paralysis).

There can be no doubt that the knowledge of scientific preventive methods
in our possession today, if universally applied, would enable us to go
far toward eliminating much of the unnecessary economic loss now chargeable
to preventable diseases in this country. That intensive application of
known scientific measures for communicable disease control can completely
eradicate certain diseases has been demonstrated repeatedly. The complete
banishment of yellow fever from the United States, Cuba, and Panama affords
an excellent example. Bubonic plague was completely stamped out in San
Francisco some years ago through the intensive application of rat control.
Many other examples could be cited.

Even in the face of the lack of adequate health service in much of our
rural area and in many of our cities, remarkable progress has been made
in the reduction of deaths from communicable diseases in the United States
during the past half century. Fifty years ago

25

infectious diseases prevailed to such an extent and were accompanied
by such a high case-fatality rate that fifteen-sixteenths of all deaths
were chargeable to this group. Today, as a result of only a partial application
of known scientific methods, deaths from communicable diseases have dropped
to less than 50 percent of the total.

Numerous instances could be cited where intensive health work carried
on by county health organizations has reduced sickness and mortality rates.
In one county the health department conclusively demonstrated between
1927 and 1932 that maternal deaths could be greatly reduced in number
when prenatal cases came under supervision of the department. With only
10.8 percent of mothers under supervision in 1927, the maternal mortality
rate (deaths per 1,000 births) was 7.4, whereas in 1932, with 74.1 percent
of the mothers under supervision, the rate was 2.2 per 1,000 births.

In another county, in 1911, where typhoid was prevalent, as cooperation
of the local, State, and Federal Governments in sanitary improvements
proceeded, the incidence of typhoid fever markedly diminished instead
of rapidly increasing as usual in early summer. The county health department
began full-time operation in 1911 and the average of 3-year annual death
rates from all causes during 1912-14 was over 100 deaths less than the
number in 1910.

In addition to specific instances of help in localized areas, the Public
Health Service has worked on research investigations, either international
or interstate in character, or problems of long-time and higher-cost study
than States or communities can afford. For instance, the Public Health
Service has been engaged in the study of stream pollution and sewage disposal
for the past 20 years. The increasing pollution and dumping of industrial
wastes into these streams have made it imperative for the Service to investigate
the biological facts in connection with stream purification and necessary
control of the situation through adequate sewage and waste disposal.

Another problem of importance and one which demands immediate attention
is that of mottled enamel, a disfiguring condition of the teeth caused
probably by excessive amounts of fluorine in the water supply. The problem
is not only one of public-health importance, but also of economic importance,
since it may prevent further settlement of rich land areas where the condition
is prevalent. A study of the permissible amounts of fluorine in the drinking
water and of a method to remove excessive amounts is most urgently needed.

There is probably no field of investigation where there is need for greater
development than in industrial hygiene. Not only is every State affected
but the great majority of the 48,000,000 persons in this country engaged
in gainful occupations are directly or indirectly affected, as are their
families. The health hazards of industries are

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almost as diversified as are the number of different industries. Here
again, the cost of investigations leading to the prevention of incapacitating
industrial disease is extremely small compared to the economic values
accruing to both industry and the industrial worker. With its limited
funds the Public Health Service has contributed considerable aid in this
special field. Acting as an impartial fact-finding body its investigations
are accepted by the general public and by both labor and industry. Its
studies of the health hazards of dusty trades, so far as time and funds
have permitted, especially in the field of silicosis, a disease which
affects workers in many industries wherever silica is quarried or used,
serve as one of the principal guides for the control of the disease in
this country.

So far as it has been possible, the Public Health Service has attempted
to meet the demands of State health authorities in the investigation of
diseases which are interstate in character or which have appeared in epidemic
form. The ultimate control of all epidemic diseases, even the more common
ones such as measles, diphtheria, and scarlet fever, can come only from
continued epidemiological investigations of such diseases and by laboratory
studies of the nature of the causative agent and the development of vaccines
or serums for their prevention and cure. In 1933 the epidemic of encephalitis
at St. Louis resulted in an excellent cooperative investigation under
the general direction of the Service with the State, city, and the universities
of the city of St. Louis. Besides the pertinent facts gained in the epidemiological
survey--of benefit to the entire world--the virus of this disease was
for the first time successfully transferred to animals, offering thereby
an opportunity for the continued study of the disease in nonepidemic times.
Epidemics of infantile paralysis which occur in some State or city almost
annually have required Federal cooperation since the preliminary investigation
of 1910. From field and laboratory studies in regard to this disease has
come a substantial knowledge upon which hope of control and prevention
can be based.

Venereal diseases form one of our major social problems in causing disability
during the most active years of life as well as contributing substantially
to the death rate in the older age periods. The Public Health Service
has attacked these problems--first, in aiding States in the development
of venereal-disease clinics for the treatment of those already infected,
a measure which has been extensively tried out in England with an actual
reduction in infected cases in the last few years; second, in cooperative
studies on treatment in the cure of syphilis; third, the study of methods
of making recently infected cases noninfectious in order to prevent the
spread of the disease.

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The few brief examples of the type of public-health investigations which
are carried on by the Public Health Service do not in any way cover the
whole field of public health, nor do they give any evidence of the number
of similar problems of equal importance which are now before the Service.
They do serve, however, to explain the interstate and national aspects
of the investigational work of the Service.

RESPONSIBILITY FOR PUBLIC
HEALTH

The protection and promotion of the public health has long been recognized
as a responsibility of governments--national, State, or local. In the
United States, however, this responsibility has not generally been discharged
in so systematic or adequate a manner as such other functions of government
as the protection of property, the provision of means of communication
(highways, postal, and similar services), the administration of justice,
and education. There is, in fact, marked inequality of health service
now being rendered in different communities, resulting in unequal opportunities
for citizens to acquire and maintain health. These differences derive
from:

(1) Lack of local services for organized health protection; (2) lack
of appreciation and understanding on the part of citizens of the measures
necessary to preserve and promote individual health; and (3) lack of ability
of citizens and communities unaided to obtain needed preventive services.
The improvement of economic security in this country requires a comprehensive,
Nation-wide program of public health, supported and administered by local
communities and by States, financially and technically aided by the Federal
Government.

Aside from certain services such as the improvement of a water supply
or the provision of safe means of sewage disposal, the improvement of
public health depends upon the summation of the improvement of protection
of individual health. Health services, therefore, are best rendered on
a community basis, localized or individualized to the greatest degree
commensurate with economy of administration. The responsibility of government
is twofold:

(1) It should supply those facilities which can best be maintained on
a community basis and which the individual cannot be expected to provide
for himself; (2) it should, through mass education, acquaint the citizens
with the health problems, the local facilities available, and the advantage
to himself and to the community of making early and full use thereof.

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BASIC REQUIREMENTS OF LOCAL PUBLIC-HEALTH
SERVICES

What, in the opinion of public-health experts, are the basic requirements
of public-health services in a community? In the following brief outline
and discussion, the standards established by the American Public Health
Association have been kept closely in mind.

Nature of Local Organization.-The basis of a satisfactory health
service in a community is a well-organized health department, adequately
financed, with trained personnel, supported by suitable laws and ordinances,
by favorable public opinion, and by all professional groups. Recognition
of the need of a large population unit, and the importance of a full-time,
trained, administrative head has led away from the establishment of services
on the town or village basis to the county or district (city or groups
of cities, part of county, or combination of counties) of 50,000 population
or more, in a reasonable compass, as the unit of organization.

The basic principles of organization of such service in a community are:

(1) That the health administrative agency be a recognized part of the
government of the area and be correlated with the government of the State;

(2) That in view of the responsibilities which must be placed upon the
health officer or administrative head of such services, a board of health
or advisory council be established as an essential factor in the administrative
plan to advise the health officer regarding policies and otherwise to
bring a broader community viewpoint to the administration of the service;
and that such a board or council include physicians, members of other
public-health professions, and representatives of the general public;

(3) That the health officer be (a) selected and appointed on the basis
of professional qualifications and protected against political interference,
( b ) adequately compensated commensurate with the public responsibilities
placed upon him, (c) required to devote his full time to the duties of
his office, and (d) directly responsible either to the board which may
have the appointing power or to the chief government executive of the
area;

(4) That the major divisions of the department likewise be directed by
full-time trained persons responsible to the health officer.

Local Health Services.-The physicians in a community, whether
in private offices, clinics, hospitals, or homes, perform a service in
the treatment of disease either as individuals or as members of organized
groups. This is the usual form of medical care in this country for those
able to pay for such services. Because of their training, numbers, and
relationships to their clientele, physicians in private practice constitute
the group which is potentially most capable of applying the lessons of
preventive medicine to the habits and circumstances of the individual.
The public generally, however, is not yet accustomed to demand or privately
pay for such guidance in the application of preventive medicine to its
own or its com-

329

munity's health problems. The program of local health work must, therefore,
provide for activities which will:

(1) Carry out the legal responsibilities in disease control imposed,
by law;

(2) Provide those facilities for institutional care (acute communicable
disease, including tuberculosis), laboratory service, and diagnostic aid-services
which the individual patient cannot provide for himself alone;

(3) Stimulate a public demand for services in the prevention of illness;

(4) Supplement the services of the private physician in the community;

(5) Aid in developing the interest and ability of physicians to render
preventive services in their private practice.

A comprehensive local health program will include services aimed at the
control of preventable diseases (the acute communicable diseases, syphilis
and gonorrhea, tuberculosis), heart disease, cancer, industrial disease,
and mental diseases; care of crippled children; improvement of nutrition;
the promotion of maternal, infant, ,and other child-health services; the
supervision of general sanitary conditions of the community; services
for diagnostic aid (laboratory services and expert consultants) ; and
service for the collection, tabulation, and analysis of vital statistics.
Health conferences or health-center preventive and medical services conducted
by the health department or other agencies in cooperation with medical
groups, especially for mothers and children, are justified and desirable
as a means of creating a demand for such services, as a practice ground
for physicians in the art of preventive medicine, as an agency for inaugurating
proper standards for such services, and as a supplement to the preventive
services of private practitioners.

Cost of Local Service.-Experience with well-organized and well-administered
health services in many county and city departments indicates that an
expenditure of $1 per capita from official funds is required to provide
these essential services for community health protection in the minimum
effective degree. This minimum cost is based an the assumption that the
preventive services by private physicians rendered in their own practice,
as above outlined, will be improved and maintained. Many cities and some
rural areas have found it desirable and profitable, in terms of increased
protection, to develop services in excess of these minimums.

Since, as has been pointed out, the responsibility for the provision
and administration of the public-health program rests primarily with the
government, it follows that the major support of this service must be
met through local taxation. Studies of the ability of counties to meet
the cost of health administration from local resources show a wide variation
and suggest the need that State governments be prepared where necessary
to assist local communities in providing the minimum health program compatible
with protection for the State.

330

Such assistance is already being given to some degree in certain States
and takes the form either of supplying service which can be satisfactorily
rendered from the State department of health or of direct grants of money
(through the State health department) to aid the local program, or both.
In addition to the advantage of building up a sound local program, appropriations
for State aid exercise a beneficial influence upon the standardization
and improvement of the character of local work throughout the State. The
need of trained personnel for effective local health work makes it imperative
that the State be prepared to assist local communities by furnishing especially
qualified persons and by providing special training services as already
done in a number of States.

Studies of local health services, both in urban and rural communities,
indicate that the minimum essentials of service, as outlined here, will
require more than $1 per capita; {8}that a comprehensive program
will require in addition facilities for the hospitalization of certain
acute and chronic diseases. Unusually acute health problems, regional
or special problems, or great community interest and demand for service
may require additional services not provided in this program and budget.
Some cities and rural areas have demonstrated that as much as $2.50 per
capita {9} can be wisely and profitably expended. In such forward-looking
programs, voluntary agencies usually participate to a substantial degree
in money support. If we consider, however, $1 per capita for the field
program, aside from institutional facilities and hospital care, the total
allotment for public health in the local tax budgets would be' $126,000,000
a year, representing less than a mill on the gross assessed property valuation
of $163,000,000,000 in 1931.{10} It is evident that a reasonable levy
over the entire country would yield sufficient funds to carry this minimum
program. It is recognized that assessed valuations vary from one period
to another in their relation to the true value in different areas, and
that the proposal of a specific tax rate to be generally applied has limitations.
Considering the problem broadly, the total assessed valuation with specific
millage for health purposes is used as a practical and convenient basis
of discussion. The problem, however, is one of distribution, since not
all corriniunities have sufficient resources to support such a program
with a reasonable tax rate. The solution of this problem necessarily rests
with the State and the Federal Government.

{8}American Public Health Association, An Official Declaration of
Attitude on Desirable Standard Minimum Functions and Suitable
Organization of Health Activities, approved on Tuesday,
Oct. 10, 1933, Indianapolis, Ind. (American Public Health Association,
New York City, 1933).

The following tabulation indicates for the counties of a southern State
the money needed for a minimum health program and the amount which a reasonable
tax of 1 mill would yield:

County

Cost of minimum effective local program

Yield of a1-mill tax levy

A

$22,845

$17,579

B

23,929

15,589

C

32,286

19,339

D

28,800

15,595

E

232,200

273,818

Total

340,066

341,920

It is evident that all but one of these counties must have outside assistance
even if only minimum health services are rendered locally, for the tax collected
within the county boundaries will be insufficient to finance the health
program.

Obviously not every community and not every political subdivision is
large enough or wealthy enough to equip itself with facilities and personnel
to meet satisfactorily its health needs. Many communities, on the other
hand, ire amply able to provide financial support for their own health
programs and to lend assistance to other less able communities. With present.
methods of travel, there is no isolated part of the country. Communicable
diseases may readily and rapidly spread beyond political boundaries. The
flow of travel is to the more urban areas which are also more able to
provide for an adequate health program. To meet this condition health
services are organized on a city, county, or district basis in order to
provide a sufficiently large aggregate of population and wealth to support
efficient organization. Yet, there are services which the local community
cannot and should not provide for itself alone. These needs should be
met through assistance from the resources of official State or Federal
health agencies or from local voluntarily supplied resources for health
service, or both.

Voluntary and nonofficial agencies at present provide approximately one-fourth
of the support of all public-health work in the country.{11} Such agencies,
assisting in the local health program, have grown up more extensively
in cities than in rural areas because these areas contain a larger proportion
of individuals who are conscious of the acute public-health problems and
who also have available funds to support such work. The services which
these voluntary agencies render include public-health nursing, promoting
health education, maintaining clinics of a public-health nature, initiating

{11}White House Conference on Child Health and Protection, Public Health
Organization (Century Co., New York. 1933).

332

studies of local problems, and encouraging the maintenance of sound standards.
It is believed that the continued participation of voluntary groups in
the community health program should be encouraged in order to provide
services supplemental to the official activities which the local official
agency may not be equipped or ready to render. Usually through their extensive
roots in the community the voluntary groups are able to affect public
opinion favorably and thus bring support for a well-rounded public-health
program which the health officer finds exceedingly helpful. They have
further responsibility in aiding the development of new fields of activity
beyond the minimum essentials of health service here discussed.

THE FUNCTIONS OF STATE HEALTH
DEPARTMENTS

With health services organized and administered locally as discussed
above, the function of the State health department becomes that of (1)
stimulating local areas to recognize their health problems and (2) organizing
the necessary facilities to handle them adequately. The State should assist
in providing those services which it is uneconomical for the, local community
to provide for the sole use of a small population unit. This may include
laboratory facilities and special technical services in handling problems
of sanitation, water supply and sewage disposal, occupational diseases,
facilities for the institutional care of tuberculosis, etc. The State
should also provide advisory and supervisory service to the local administrator
and through standards of performance of professional service assist the
local health officer in keeping local work at an effective level. The
training of public-health personnel for work in the local area should
be as much a State responsibility as is the training of teachers in education.
Only in limited fields and under unusual circumstances should the State
department become an agency functioning directly in the local community
dealing personally with the public.

Organization of State Health Departments.-The form or organization
of State departments of health is similar in character to the local organization
already discussed. There should be a well-trained and especially qualified
commissioner or State health officer supported by a board of health or
advisory council, the members of which should be appointed without political
regard and solely far the knowledge which they can bring to bear upon
the health problems of the State and their contribution to the solution
of these problems. Such a body should assist the State health administration
in the formulation of policies and in the preparation of the sanitary
code. The bureaus of the State health department should be headed by especially
trained and qualified individuals devoting full time to the

333

service. A plan of organization which has been found effective in practice,
and which conforms to the plan of local organization just discussed, would
provide for a commissioner of health with a supporting advisory body appointed
by the Governor and a department comprising a major division of central
administration having to do with the stimulation, guidance, and supervision
of county and other local health work. Auxiliary divisions would provide
services for the control of preventable diseases including epidemiology,
maternal and child health, laboratory service, and sanitary engineering.
A division concerned with the collection, tabulation, and analysis of
vital statistics completes the organization of the department. As the
function of the department is largely advisory and supervisory, the number
of subordinate persons needed is relatively small.

Aid to Local Health Services. Since at the present time
less than one-fourth of the counties of the country have organized full-time
health departments and nearly 50 percent of the population is without
full-time health supervision, State departments have a major responsibility
in acquainting local government officials and the public at large with
the importance and advantages of effective local health service. It is
conservatively estimated that not more than 25 percent {12} of the counties
having organized full-time health departments and not more than 50 percent
{13} of the cities have as yet developed their departments to include
efficient service in the minimum essentials of health protection and promotion
here outlined. The State's responsibility for effective health service
extends to such areas as well as to the areas which at present have no
organized health departments. In fact, it must assume a continuing responsibility
for the stimulation of the local departments to avail themselves of new
knowledge of public-health protection.

An equally important function of the State department is that of aiding
poorer counties and local areas through direct subsidy to obtain a satisfactory
health program. Not all counties within the State will be in position
to raise the necessary, funds for a satisfactory program from local taxes.
It frequently happens that the magnitude of local health problems is overwhelming,
and the responsibility for the solution of these problems does not rest
entirely upon the local community. The State, then, through its general
taxing power, must act as an equalizer and, through services rendered
or direct monetary contributions to such areas, or both, insure the conduct
of a satisfactory program and the protection of the citizenry as a whole.
The precedent for participation of the State

in the financing of local government is found in the administration of
schools and highways.

The guiding and supervisory functions which have already been discussed
as responsibilities of the State are much easier and more effectively
administered if the State assists the local area financially in carrying
its health service. However, not all States are able, within their local
resources, to meet the demand of health work, and there is a national
problem of adjustment which must be met through Federal aid to States
in the organization of State administrative services and in assisting
the States to carry the burden of the poorer counties. An analysis of
the assessed valuation and the cost of minimum effective health programs
of local services by counties shows a tag deficiency in available resources
on the basis of a 1-mill, tax levy of $13,409,000 for the country as a
whole. States must look to the Federal Government for same assistance
in meeting this problem.

Cost of State Health Work.-To carry out the normal functions of
a State health department, including the stimulation and guidance of local
health work, the State health department will need a staff, in addition
to the health officer, of approximately 6 people per 100,000 population.
The size of personnel will vary with the area and population density of
the State. For example, groups of people in sparsely settled areas will
require more personnel per 100,000 population. Such services as are usually
provided, excluding institutional care, now require an expenditure of
not less than 20 cents per capita. In addition, the State will need funds
for aid to local health work on a county basis averaging about $5,000
per county to cover the cost, in part at least, of those services which
are rendered locally but have a definite State implication and provide
protection to citizens outside the county. On such a basis of organization,
the total cost of State administration throughout the United States is
$40,000,000 ($25,000,000 for State-administered service plus $15,000,000
for subsidies to counties) apart from additional subsidies to counties
whose residents are too poor to carry the tax burden of the health program.
This is an increase of $26,000,000 over the present expenditure. The need
of this increase is better understood when it is realized that only 20
percent {14} of the States at the present time have a program of administration
which comprehends the responsibilities of the State department just discussed;
and, moreover, several of these programs are at present not adequately
financed to permit effective operation. This total cost of State health
service, aside from the funds needed to level the inequalities of county
re-

{14}Health Departments ofStates and Provinces of
the United States and Canada, United States Public Health Service,
PublicHealth Bulletin No. 184; (U. S. Government Printing
Office, Washington, D. C., 1929).

335

sources, would amount to 32.5 cents per capita for the country as a whole.
The average expenditure in 1934 was 10 cents per capita. The range of
expenditures is from 1 cent to 43 cents per capita, with only four States
appropriating 20 cents or more per capita.

FEDERAL RESPONSIBILITIES
FOR THE PUBLIC HEALTH

The policy of leaving to localities and States the entire responsibility
for providing even nominal public-health facilities and services has failed
in large measure. The uneven development of health service in the United
States has resulted largely from expecting local governments to take the
initiative in the organization of health activities. An adequate program
with the necessary local and State support for public-health services
calls for broader planning and more uniform and intensive stimulation
of communities and governmental officials to recognize and meet their
responsibilities for public health. The Federal Government has a definite
responsibility for the protection of all the Nation's population against
disease.

The responsibility of the Federal Government for national health is already
accepted by the conduct of health activities through several Federal agencies.
Furthermore, it is well recognized that the constructive development of
public-health work cannot proceed in an effective manner throughout the
entire country without assistance from the Federal Government. As has
been shown, local and State governments have a great responsibility for
the provision of more adequate health service. Public health, a primary
government function, has for years received a relatively small share of
local, State, and Federal appropriations. Recently, even these modest
appropriations and this limited service have been reduced in drastic proportions
in many localities. The experience of cities in 1934 shows that health
budgets have been reduced on the average about 20 percent from the experience
of 1931, reductions varying from 1 or 2 percent to as high as 50 percent.
Where this reduction has amounted to 30 percent or more, practically complete
breakdown of the public-health protective facilities has resulted. National
support of local health activities is indicated as a necessary development
to insure that public-health measures may go forward hand in hand with
constructive economic measures in meeting the present critical national
situation. Though public health, unlike certain of the social problems
under consideration at the moment, is not solely an emergency demand but
a continuing responsibility, the early development of a reasonably adequate
public-health program reaching both the centers of population and the
far corners of rural areas is urgently

336

needed if the people of the Nation are to receive the care which they
deserve and which scientific health service will give them.

Such a program of national health service would provide for the coordination
of Federal, State, and local funds and activities, the training of necessary
administrative and scientific personnel, the setting up of adequate standards
of efficient administration, the evaluation of results, the efficient
use of Federal, State, and local funds, and the resources of voluntary
agencies according to the needs as determined by health and not by political
conditions.

The public-health responsibilities of the Federal Government already
recognized and to a degree provided for are:

(1) The study of international health conditions and the protection of
the country from international hazards to health;

(2) The study of national health conditions and control of interstate
transmission of disease by regulation of the movement of persons and goods;

(3) The use of all educational means to promote public interest in disease
prevention and control, in safeguarding the lives and health of mothers
and children, and in the health of the worker, and in the attainment of
more complete physical and mental health;

(4) The promotion of the study of hygiene and public health as a recognized
part of education;

(5) The stimulation of States and local governments to organize health
activities as discussed to insure more effective service to all people;

(6) The provision of personnel to State and local departments for consultation,
education, demonstration, and other technical services (the training of
workers for all aspects of public-health service is necessarily a part
of this responsibility);

(7) The development and promotion of standards of performance of technical
services in the several fields, including general administration;

(8) The conduct and coordination of research in any or all aspects of
public health, particularly those problems beyond the capacity of local
and State organizations relating to disease prevention, control of the
incidence of morbidity and mortality at all ages, the influences-physical,
social, economic, and mental--affecting or contributing to a more healthy
people;

(9) The provision of direct grants to States to encourage the organization
of State and local health services for all people in accordance with current
knowledge and to equalize the tax burden of the public-health program.

These responsibilities are now met through the services of a number of
different bureaus in several Federal departments. The Federal agencies
which have to do, for the most part, with the problems of State and local
health work are:

United States Public Health Service,
Children's Bureau,
Bureau of the Census,
The Office of Education,
Food and Drug Administration,
Bureau of Animal Industry.

Other divisions having certain public-health aspects and responsibilities,
yet not directly nor uniformly concerned with the promotion

337

and administration of local health work, are: Bureau of Labor Statistics,
Women's Bureau, Employees' Compensation Commission, Consular Service,
Office of Indian Affairs, National Park Service, Bureau of Mines, Bureau
of Dairying, and the Bureau of Home Economics. These Federal services
have grown up in response to the recognized public need and each, within
its field, contributes markedly to public understanding and appreciation
of health and to the improvement of the national health. With all the
public interest over a long period which the present organization of services
in the various departments indicates, the Federal responsibility in the
specific fields just mentioned is still far from adequately met, owing
primarily to lack of resources specifically directed toward the promulgation
of a national plan of health services.

It is obvious from the wide responsibilities and their dispersion among
many departments that the efficient administration of a national health
program under the Federal Government demands the close coordination of
these health services. Such coordination can be assured in part through
the detail of qualified personnel from the United States Public Health
Service and through its study and solution of special health problems
which may arise within local departments where the health aspects of the
program are subordinate to other considerations. This procedure has already
developed with the Bureau of Indian Affairs, Bureau of Immigration, Bureau
of Mines, Employees' Compensation, Coast Guard Service, Bureau of Standards,
Federal Emergency Relief Administration, and the National Park Service.
Many bureaus are deeply interested in various aspects of public-health
promotion and protection and are carrying on effective educational and
regulatory activities. The precedent of Federal aid to States for State
health administration and local public-health facilities has been established
in various laws for granting aid and in loans of technical personnel to
States and localities.

The Cost of a National Program.-Federal agencies previously mentioned
are now spending a total of slightly more than $5,000,000 in the discharge
of their responsibilities directly related to public health. The Federal
agencies primarily concerned with public health need far more funds than
heretofore provided for trained personnel to be made available to States
or local areas for the purposes of demonstration and initiation of work
to inaugurate the enlarged State program discussed. The appropriations
for further research activities by the United States Public Health Service
and the United States Children's Bureau have been grossly inadequate.
The more important of these problems arise

(1) As requests for aid from State health officers, for problems usually
interstate in character, such as malaria, typhus fever, Rocky Mountain
spotted

(2) As a result of the requirements placed upon the Public Health Service
by law, such as the control of biological products, development of standards
and of new biological products.

(3) Within the Public Health Service to meet a national emergency of
the future or other changing conditions, such as sewage disposal, water
purification, cancer investigation, and public-health education.

(4) In the fields of maternal and child hygiene, including studies of
mortality, growth, development, and diseases of children, mental health,
and the relation of economic and industrial conditions to the health and
welfare of children and mothers.

This research work is an integral part of the national plan of public-health
services since the investigations undertaken are essentially concerned
with problems of a regional or interstate character. The solution of these
problems is not only of national significance but of vital importance
to the State health officers in allowing them to utilize fully the State
and Federal funds available to them in the prevention and control of disease,
the improvement of the environment, and the promotion of health. The majority
of such research problems come to the Public Health Service from the health
authorities of the several States.

PUBLIC-HEALTH PROVISIONS
OF THE SOCIAL SECURITY ACT

Recognizing the role of sickness as a cause of insecurity, the prevention
of disease as the most humane and the least expensive method of dealing
with this cause of insecurity, and the need for extension of Federal,
State, and local public-health service, Congress authorized an appropriation
for public-health purposes in the Social Security Act. For the fiscal
year ending June 30, 1936, and annually thereafter the sum of $8,000,000
{15} was authorized for allotment to assist States, counties, health districts,
and other political subdivisions of the States in establishing and maintaining
adequate public-health services, including the training of personnel for
State and local health work.

The Surgeon General of the Public Health Service, with the approval of
the Secretary of the Treasury, is made responsible for the administration
of these grants to States. After consultation with a conference of the
State and Territorial health authorities, he will determine the rules
and regulations for the allotment of the State grants. The amounts allotted
will be based upon the popula-

{15} The Social Security Act was not approved until Aug. 14, 1935, and
the supplemental appropriation bill, fiscal year 1936 [H. R. 9215], failed
of passage in the first session of the Seventy-fourth Congress. The Supplemental
Appropriation Act, fiscal year 1936, Public, No. 440, 74th Cong., 2d sess.
[H. R. 10464], approved Feb. 11, 1936, included an appropriation of $3,333,000
for the remainder of the fiscal year ending June 30, 1936.

339

tion, the special health problems, and the financial needs of the respective
States.

Prior to the beginning of each quarter of the fiscal year the Surgeon
General will determine the amount to be paid the State for the quarter
and will certify this amount to the Secretary of the Treasury. The grants
after certification will be paid through the Division of Disbursement
of the Treasury Department, prior to audit or settlement by the General
Accounting Office. If any part of the grant to any State remains unpaid
at the end of a fiscal year, the unexpended balance due a State will be
held available for disbursement to the States in the next fiscal year
in addition to the amount appropriated for the new period.

The Federal funds granted to States under the provisions of title VI
are to be expended solely for establishing and maintaining adequate public-health
services and for the training of personnel for State and local health
work.

The Surgeon General proposes to use the funds for Federal grants to the
States for the following purposes:

(1) To strengthen service divisions of State health departments;

(2) To assist in providing adequate facilities in State health departments
especially for the promotion and supervision of full-time city, county,
and district health organizations;

(3) To give, through the State health departments, direct aid toward
the development and maintenance of adequate city, county, and district
health organizations;

(4) To assist in developing trained personnel for positions to be established
in the extension of city, county, and district health organizations;

(5) To provide, through the State health departments, aid in the purchase
of biological products and other drugs needed for individual immunization
and other preventive activities among the poor.

While it is considered unlikely that all of that part of the $8,000,000
allocated to aid of State and local health organizations which would be
used for the development and maintenance of full-time county or district
health units could be utilized satisfactorily in the organization of such
units during the first year, it is proposed that the funds available for
this purpose could be used to great advantage temporarily to aid the most
needy of the 2,000 counties now without any health service whatever in
providing at least a public-health nursing service until adequate full-time
health service under fulltime specially trained medical health officers
can be established.

It is further proposed that funds will be allotted to the States on the
basis of budgets showing contributions from State and local sources for
each project for each year, and that the maintenance of certain generally
accepted standards of personnel qualifications and service will be required.

340

Under the Surgeon General's regulations for the fiscal year 1936 {16}
for the allotment of State grants on the basis of (1) population, (2)
special health problems, and (3) financial needs, the following apportionment
has been made: 57.5 percent of the total sum available for the year 1936
will be allotted on a per-capita basis; 22.5 percent of the total sum
will be allotted to the several States on a basis of special health problems;
and 20 percent of the total sum for 1936 will be allotted to the States
on a basis of financial need.

Payments to aid existing State or local projects will not replace State
or local appropriations already made for such projects but will supplement
such appropriations.

Payments to States from the fund to be allotted on the basis of population
(1930 census) fall under two classifications: (1) One-half of the amount
thus apportioned will be used to match (dollar for dollar) existing appropriations
of public funds within the State for public-health work. (2) One-half
of the apportioned sum will be used to match (dollar for dollar) new appropriations
or appropriations made for the specific purpose of matching funds to become
available under the Social Security Act, subject to modification by the
Surgeon General where States already have made substantial appropriations.

Payments to States from the fund to be allotted on the basis of special
health problems fall under two classifications: (1) For special health
needs, to include unusual exposure throughout the State to public-health
hazards as in the case of certain types of epidemics or special industrial
hazards, 10 percent of the entire appropriation for payments to the States
will be allotted to be matched (dollar for dollar) by the States. (2)
The remaining apportionment to be used for payments to the States on the
basis of special health problems will be allotted, in accordance with
the needs of the several States, for the training of personnel, establishment
of suitable training centers, and payment of living stipends, tuition,
and traveling expenses of trainees. The States will not be required to
match these payments.

Payments to the States from the sum apportioned to be allotted on the
basis of financial need fall under two classifications: (1) One-fourth
of the amount will be used for payments to the 51 State and Territorial
health jurisdictions to which the act applies to assist in providing leadership
and administrative guidance in the effective use of Federal aid. The States
will not be required to match these payments. (2) Three-fourths of the
allotment will constitute an equalization fund to be used in assisting
States most in need of

{16} "Regulations Governing Allotments and Payments to States from
Funds Appropriated Under the Provisions of Section 601, Social Security
Act, for the Fiscal Year 1936", American Journal ofPublic
Health, vol. 26, no.1, January 1936, pp. 59-62.

341

financial aid. These funds are to be used for local health services exclusively.
State financial participation is not required.

In addition to the amount authorized for aid to the States, the Social
Security Act authorizes an appropriation for the extension of public-health
investigations by the Public Health Service. An annual appropriation of
$2,000,000{17} was established for each fiscal year beginning with 1935-36,
to be expended by the Public Health Service for investigation of disease
and problems of sanitation and for the pay, allowances, and traveling
expenses of commissioned officers and personnel of the Public Health Service
engaged in such investigations or detailed to cooperate with the health
authorities of any State. Other personnel of the Service may also be detailed
to assist in this investigation or cooperation with the States, and the
account from which they are paid may be reimbursed from the $2,000,000.
The act provides, however, that a request for Federal cooperation with
a State must come from the proper State authorities before personnel may
be detailed from the Federal Service to assist a State in the extension
of its public-health work.

The Surgeon General of the Public Health Service proposes to use this
annual appropriation of $2,000,000 for the following purposes:

(1) The employment of personnel necessary to maintain supervision and
guidance over the expenditure of funds annually allotted to the States,
and in such manner to render assistance to them in the continuous and
steady development of State and local health services;

(2) The employment of professional, technical, and other personnel necessary
to conduct the investigational work of the Public Health Service;

(3) The extension and broadening of the investigative work of the Service
in relation to investigations of diseases, sanitation, and matters related
thereto.

The major portion of the investigative work arises from three general
sources:

(1) From problems which are interstate in character and which are brought
to the Service by State health officials, through the cooperative work
of the Service with the States.

(2) From problems which arise within the Service as a result of the responsibilities
placed upon it by law, as, for example, the development of biologic standards
in connection with the control of biologics.

(3) From problems which the trends of public health indicate will be
of national or international importance in both the fields of environmental
sanitation and the control of disease.

{17} The Social Security Act was not approved until Aug. 14, 1935, and
the supplemental appropriation bill, fiscal year 1936 [H. R. 9215], failed
of passage in the first session of the Seventy-fourth Congress. The Supplemental
Appropriation Act, fiscal year 1936, Public, No. 440, 74th Cong., 2d sess.
[H. R. 10464], approved Feb. 11, 1936, included an appropriation of $375,000
for the remainder of the fiscal year ending June 30, 1936, for the purposes
of section 603 of the Social Security Act, section 1 of the act of Aug.
14, 1912, and section 6 of the act of Aug. 23, 1912 (31 U.S.C., Sec. 669).

342

It is evident, therefore, that to a large extent this investigative work
of the Public Health Service is noncompetitive with the research work
of universities or States.

It should be clearly understood that the additional funds which are appropriated
do not mean so much the development of new fields of investigational work
in the Public Health Service as (1) the opportunity for a more immediate
and broader study in the fields of work which the Service is at present
carrying on, and (2) undertaking problems of the greatest national importance
which hitherto have been refused or delayed because of the lack of necessary
funds.

It would seem a corollary that the full benefits of the funds allotted
to the several States for the promotion of public health cannot be achieved
if the public-health problems with which these States and their local
subdivisions have to deal are not studied coincidentally and the information
given to the health authorities of the States.{18}

In connection with the administration of the funds authorized by the
Social Security Act for aid to States and the extensive research activities
to be carried on by the Public Health Service, it will be necessary to
have additional medical, sanitary engineering, and other officers. The
number of officers already in the Public Health Service who have the required
training in public-health work and research methods will be entirely inadequate
to meet the immediate demand for personnel of this type. The Public Health
Service, therefore, must plan to obtain from outside sources the highly
specialized, thoroughly trained, medical, engineering, and other officers
of ability that will be needed. It will be impossible to attract personnel
of this type to the Service unless they can be offered either larger salaries
than they are now receiving or other inducements. The advantages of a
career in the Public Health Service in a commissioned status will, it
is believed, attract, at much lower entrance salaries, many individuals
who otherwise would not be interested. This will enable the Public Health
Service to obtain at once the desired personnel at much lower cost to
the Federal Government, probably as much as one-third less. Officers commissioned
in the Service now would not for several years receive salaries equaling
those being paid to individuals of comparable ability in many State and
local health departments. The technical and clerical personnel added to
the Service under the authority of the Social Security Act will be drawn
from the civil-service eligible lists.

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